88 SIGN Management of suspected bacterial urinary tract infection in adults

S I GN
Scottish Intercollegiate Guidelines Network
88
Management of suspected bacterial urinary
tract infection in adults
A national clinical guideline
1
Introduction
1
2
Management of bacterial UTI in adult women
6
3
Management of bacterial UTI in pregnant women
13
4
Management of bacterial UTI in adult men
16
5
Management of bacterial UTI in patients with catheters
18
6
Information for discussion with patients and carers
22
7
Recommendations for implementation, audit, surveillance and research
25
8
Development of the guideline
30
Abbreviations
33
Annexes
34
References
38
July 2006
Copies of all SIGN guidelines are available online at www.sign.ac.uk
KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS
LEVELS OF EVIDENCE
1++
High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1 +
Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low
risk of bias
1 -
Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++
High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2 +
Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2 -
Case control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal
3
Non-analytic studies, eg case reports, case series
4
Expert opinion
GRADES OF RECOMMENDATION
Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.
A
At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++
and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good practice points


Recommended best practice based on the clinical experience of the guideline development group
Supplementary material available on our website www.sign.ac.uk
This document is produced from elemental chlorine-free material and is sourced from sustainable forests
Scottish Intercollegiate Guidelines Network
Management of suspected bacterial
urinary tract infection in adults
A national clinical guideline
July 2006
© Scottish Intercollegiate Guidelines Network
ISBN 1 899893 79 2
First published 2006
SIGN consents to the photocopying of this guideline for the
purpose of implementation in NHSScotland
Scottish Intercollegiate Guidelines Network
28 Thistle Street, Edinburgh EH2 1EN
www.sign.ac.uk
1 INTRODUCTION
1
Introduction
1.1the need for a guideline
Urinary tract infection (UTI) is the second most common clinical indication for empirical
antimicrobial treatment in primary and secondary care, and urine samples constitute the largest
single category of specimens examined in most medical microbiology laboratories.1 Healthcare
practitioners regularly have to make decisions about prescription of antibiotics for urinary tract
infection. Criteria for the diagnosis of urinary tract infection vary greatly in the UK, depending
on the patient and the context. There is considerable evidence of practice variation in use of
diagnostic tests, interpretation of signs or symptoms and initiation of antibiotic treatment, 2-5
with continuing debate regarding the most appropriate diagnosis and management.1,6
The diagnosis of UTI is particularly difficult in elderly patients, who are more likely to have
asymptomatic bacteriuria as they get older.7 The prevalence of bacteriuria may be so high that
urine culture ceases to be a diagnostic test.8 Elderly institutionalised patients frequently receive
unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse
effects with no compensating clinical benefit.9,10
Existing evidence based guidelines tend to focus on issues of antibiotic treatment (drug selection,
dose, duration and route of administration) with less emphasis on clinical diagnosis or the
use of near patient tests or are limited to adult, non-pregnant women with uncomplicated,
symptomatic UTI.11,12
For patients with symptoms of urinary tract infection and bacteriuria the main aim of treatment
is relief of symptoms. Secondary outcomes are adverse effects of treatment or recurrence of
symptoms. For asymptomatic patients the main outcome from treatment is prevention of future
symptomatic episodes.
Unnecessary use of tests and antibiotic treatment may be minimised by developing simple
decision rules, diagnostic guidelines or other educational interventions.13-16 Prudent antibiotic
prescribing is a key component of the UK’s action plans for reducing antimicrobial resistance.17,18
Unnecessary antibiotic treatment of asymptomatic bacteriuria is associated with significantly
increased risk of clinical adverse events.19,20
1.2remit of the guideline
This guideline provides recommendations based on current evidence for best practice in
the management of adults with community acquired urinary tract infection. It includes adult
women (including pregnant women) and men of all ages, patients with catheters and patients
with comorbidities such as diabetes. It excludes children and patients with hospital acquired
infection. The guideline does not address prophylaxis to prevent UTI after instrumentation or
surgery, or treatment of recurrent UTI.
This guideline will be of interest to healthcare professionals in primary and secondary care,
officers in charge of residential and care homes, antibiotic policy makers, clinical effectiveness
leads, carers and patients.

Additional epidemiological and statistical information to accompany this guideline is available
as supplementary material on the SIGN website www.sign.ac.uk
1
Management of suspected bacterial urinary tract infection in adults
1.3definitions
asymptomatic
bacteriuria
presence of bacteriuria in urine revealed by quantitative culture or
microscopy in a sample taken from a patient without any typical symptoms
of lower or upper urinary tract infection. In contrast with symptomatic
bacteriuria, the presence of asymptomatic bacteriuria should be confirmed
by two consecutive urine samples.21
bacteraemia
presence of bacteria in the blood diagnosed by blood culture.
bacteriuria
presence of bacteria in urine revealed by quantitative culture or
microscopy.
empirical treatment
treatment based on clinical symptoms or signs unconfirmed by urine
culture.
haematuria
blood in the urine either visible (macroscopic haematuria) or invisible
(microscopic haematuria).
long term catheter
an indwelling catheter left in place for over 28 days.
lower urinary tract
infection (LUTI)
evidence of urinary tract infection with symptoms suggestive of cystitis
(dysuria or frequency without fever, chills or back pain).
medium term
catheter
an indwelling catheter left in place for 7-28 days.
near patient testing
tests that are done at the point of consultation and do not have to be sent
to a laboratory.
pyuria
occurrence of ≥104 white blood cells (WBC)/ml in a freshly voided
specimen of urine.22 Higher numbers of WBC are often found in healthy
asymptomatic women. Pyuria is present in 96% of symptomatic patients
with bacteriuria of >105 colony forming units (cfu)/ml, but only in <1% of
asymptomatic, abacteriuric patients.22 Pyuria in the absence of bacteriuria
may be caused by the presence of a foreign body, for example, a urinary
catheter, urinary stones or neoplasms, lower genital tract infection or,
rarely, renal tuberculosis.
short term catheter
an indwelling catheter left in place for 1-7 days.
significant
bacteriuria
≥105 cfu/ml of a single bacterial species in a freshly voided specimen of
urine. For laboratory purposes the widely applied definition in the UK is
104 cfu/ml. For some specific patient groups there is evidence for lower
thresholds:
 women with symptomatic UTI ≥102 cfu/ml
 men ≥103 cfu/ml (if 80% of the growth is due to a single organism).
symptomatic
bacteriuria
presence of bacteriuria in urine revealed by quantitative culture or
microscopy in a sample taken from a patient with typical symptoms of
lower or upper urinary tract infection. The presence of symptomatic
bacteriuria can be established with a single urine sample.
upper urinary tract
infection (UUTI)
evidence of urinary tract infection with symptoms suggestive of
pyelonephritis (loin pain, flank tenderness, fever, rigors or other
manifestations of systemic inflammatory response).
1 INTRODUCTION
1.4
Key messages about bacterial uti
Bacteriuria is not a disease


The normal flora of the human body are extremely important as a key part of host defences
against infection and because of their influence on nutrition.23
In people less than 65 years of age bacteriuria is abnormal in the sense that most people
do not suffer from it (see Table 1). Bacteriuria is common in some populations of
institutionalised women 24 and people with long term indwelling urinary catheters
(see section 5).
Tests for bacteriuria or pyuria do not establish the diagnosis of UTI


The diagnosis of UTI is primarily based on symptoms and signs (see section 2.1).
Tests that suggest or prove the presence of bacteria or white cells in the urine may contribute
additional information to inform management but rarely have important implications for
diagnosis (see sections 2.2, 3.1.3, 4.1, 5.2).
Bacteriuria alone is rarely an indication for antibiotic treatment



Bacteriuria can only be an absolute indication for antibiotic treatment when there is convincing
evidence that eradication of bacteriuria results in meaningful health gain at acceptable
risk (see sections 2.4, 5.3, 5.4). In particular, in elderly patients, asymptomatic bacteriuria is
common and there is evidence that treatment is more harmful than beneficial.9,10 In contrast,
during pregnancy there is evidence that treatment of bacteriuria does more good
than harm.25
The main value of urine culture is to identify bacteria and their sensitivity to antibiotics (see
sections 2.3, 2.4.1, 3.1.2, 4.1, 5.4.1).
Indirect indicators of the presence of bacteria (for example, urinary nitrites) are likely to be
much less valuable than urine culture (see sections 2.2.3, 3.1.3, 4.1, 5.2.2).
There is a risk of false positive results in all tests for diagnosis of bacteriuria other than the
gold standard



The gold standard test for diagnosis of bacteriuria is culture of bladder urine obtained by
needle aspiration of the bladder as it minimises the risk of contamination of the urine
specimen (see section 3.1.2).
All other techniques (urethral catheter and midstream specimens of urine) carry a higher risk
of contamination and therefore produce some false positive results (see section 3.1.2).
The significance of false positive results is greatest when testing for bacteriuria in people
with low pre-test probability (for example, screening for asymptomatic bacteriuria in the
first trimester of pregnancy, see section 3.1.2).
Routine urine culture is not required to manage LUTI in women


Women with symptomatic LUTI should receive empirical antibiotic treatment
(see section 2.4.1).
All urine samples taken for culture will be from patients that are not responding to treatment
and will bias the results of surveillance for antibiotic resistance (see section 7.4).
Management of suspected bacterial urinary tract infection in adults
1.5
Epidemiology
1.5.1prevalence of asymptomatic bacteriuria

In women asymptomatic bacteriuria becomes increasingly common with age. The limited data
about healthy men shows that the prevalence of bacteriuria also increases with age, although
the prevalence in men is always lower than for women of the same age26-28 (see Table 1 and
supplementary material section S2.1.2).
Table 1: Prevalence of asymptomatic bacteriuria in adult men and women
Country
Age (years)
Men (%)
Women (%)
Japan
50-59
0.6
2.8
60-69
1.5
7.4
70+
3.6
10.8
72
6.0
16.0
79
6.0
14.0
65-74
6.0
16.0
>75
7.0
17.0
26
Sweden
27
Scotland
1.5.2
28
risk factors for asymptomatic bacteriuria
Table 2: Risk factors for asymptomatic bacteriuria


Risk factor
Effect on prevalence of asymptomatic bacteriuria
Female sex
Increases prevalence (see Table 1).
Sexual activity
May increase prevalence (higher in married women than in nuns, 29
see supplementary material section S2.1.1).
Comorbid diabetes
Increases prevalence in women less than 65 years of age with
diabetes from 2-6% to 7.9-17.7%.30-34
Age
Increases prevalence in women and men26-28,35-38 (see Table 1 and
supplementary material section S2.1.2).
Institutionalisation
Increases prevalence (in people over 65 years of age) from 6-16% to
25-57% for women19,39-42 and from1-6% to 19-37% for men.40-43
Presence of catheter
3-6% of people acquire bacteriuria with every day of catheterisation.
All patients with long term catheters have bacteriuria.43,44
1.5.3prevalence of symptomatic bacteriuria

Combined figures from nine studies show that women under 50 years of age with acute symptoms
such as dysuria, urgency or frequency (suggesting lower urinary tract infection) or loin pain
(suggesting upper urinary tract infection) are extremely likely to have bacteriuria (see Table
3 and supplementary material section S2.2)45-53 The prevalence of symptomatic bacteriuria in
pregnant women, men and catheterised patients is discussed in sections 3.1, 4.1 and 5.1.
Table 3: Prevalence of bacteriuria in non-pregnant women under 50 years of age with acute
symptoms of UTI45-53
Total number
of women
Number with
bacteriuria
% with
bacteriuria
Lower
confidence
interval (CI)
Upper
confidence
interval (CI)
4,135
2,960
71.6%
70.2%
73.0%
1 INTRODUCTION
1.6
Statement of intent
This guideline is not intended to be construed or to serve as a standard of medical care.
Standards of care are determined on the basis of all clinical data available for an individual
case and are subject to change as scientific knowledge and technology advance and patterns of
care evolve. Adherence to guideline recommendations will not ensure a successful outcome in
every case, nor should they be construed as including all proper methods of care or excluding
other acceptable methods of care aimed at the same results. The ultimate judgement regarding
a particular clinical procedure or treatment plan must be made by the appropriate healthcare
professional in light of the clinical data presented by the patient and the diagnostic and treatment
options available. It is advised, however, that significant departures from the national guideline
or any local guidelines derived from it should be fully documented in the patient’s case notes
at the time the relevant decision is taken.
Management of suspected bacterial urinary tract infection in adults
2
Management of bacterial UTI in adult women
The management of symptomatic bacterial UTI in adult non-pregnant women is summarised in
Annex 1 (LUTI) and Annex 2 (UUTI).
2.1diagnosis
Symptoms suggestive of acute urinary tract infection are one of the most common reasons for
women to visit healthcare professionals. Although the clinical encounter typically involves taking a
history and performing a physical examination, the diagnostic accuracy of the clinical assessment
for UTI remains uncertain.12,54
The prior probability of bacteriuria in otherwise healthy women who present to their general
practitioner (GP) with symptoms of acute UTI is estimated at between 50-80%.12
If dysuria and frequency are both present, then the probability of UTI is increased to >90%
and empirical treatment with antibiotic is indicated.12
If vaginal discharge is present, the probability of bacteriuria falls. Alternative diagnoses such as
sexually transmitted diseases (STDs) and vulvovaginitis, usually due to candida, are likely and
pelvic examination is indicated.12 Rarer causes include local vaginal and cervical pathology
including erosions and very rarely cancer.
C
In otherwise healthy women presenting with symptoms or signs of UTI, empirical
treatment with an antibiotic should be considered.
C
In women with symptoms of vaginal itch or discharge, explore alternative diagnoses
and consider pelvic examination.
2++
The presence of back pain or fever increases the probability of UUTI and urine culture should
be considered as the clinical risks associated with treatment failure are increased. Increasing
bacterial resistance means that no antibiotic is sufficiently reliable for empirical treatment of
UUTI.55,56

In patients presenting with symptoms or signs of UTI who have a history of fever or back
pain the possibility of UUTI should be considered. Empirical treatment with an antibiotic
should be started and urine culture performed to guide the choice of antibiotic.
2.2near patient testing
Near patient tests may include the appearance of the urine sample, microscopy and testing by
means of dipsticks.
2.2.1
APPEARANCE of Urine
Urine turbidity has been shown to have a specificity of 66.4% and sensitivity of 90.4% for
predicting symptomatic bacteriuria. When examined against a bright background, a turbid sample
is positive, whereas a clear sample is negative.57 Visual appearance is prone to observer error and
may not be a useful discriminator.
2++
2.2.2urine microscopy
There is wide variation in sensitivity (60-100%) and specificity (49-100%) of urine microscopy
to predict significant bacteriuria in symptomatic ambulatory women.58,59
Near patient testing by microscopy raises concerns about health and safety at work, maintenance
of equipment and training of staff which does not justify its use.

Urine microscopy should not be undertaken in clinical settings in primary or
secondary care.
2++
2 MANAGEMENT OF BACTERIAL UTI IN ADULT WOMEN
2.2.3
DIPSTICK TESTS
The quality of evidence for near patient testing with dipstick tests (reagent strip tests) was
poor.12,60 The care setting varied across the studies, for example, accident and emergency,
genitourinary medicine and hospital inpatients. Individual reagent responses were reported in
a variable and incomplete way.
A meta-analysis of the accuracy of dipstick testing to predict UTI looked at four categories of
tests: nitrite only; leucocyte esterase (LE) only; disjunctive pairing (dipstick positive if either nitrite
or LE or both are positive) and conjunctive pairing (dipstick positive only if both nitrite and LE
are positive).60 The study found the disjunctive pair test to be significantly more accurate than
the LE test alone (p=0.0001). 60 A urine sample positive for dipstick tests for LE or nitrite is less
likely to predict bacteriuria than combinations of symptoms and signs, particularly combinations
of confirmatory symptoms (dysuria, frequency) and absence of features that suggest alternative
diagnoses (vaginal discharge and irritation).12
2++
Dipstick tests are only indicated for women who have minimal signs and symptoms and
whose prior probability of UTI is in the intermediate range (around 50%). Where only one
symptom or sign is present, a positive dipstick test (LE or nitrite) is associated with a high
probability of bacteriuria (80%) and negative tests are associated with much lower probability
(around 20%).60

Negative tests do not exclude bacteriuria. A randomised controlled trial (RCT) of near patient
testing in adult women who were symptomatic but had a negative dipstick test showed that
antibiotics (trimethoprim 300 mg daily for three days) improved symptoms with the median
duration of constitutional symptoms being reduced by four days. Although the probability of
UTI is reduced to less than 20% by a negative dipstick test, the evidence suggests that women
still derive symptomatic benefit from antibiotics, number needed to treat (NNT) of 4.61 For
statistical methods see supplementary material section S1. These issues should be considered
and explained to symptomatic women with a negative dipstick test. Clinical judgement should
be used to decide whether to obtain urine for culture or invite the patient to return if symptoms
persist or worsen.60
B
1+
2++
Dipstick tests should only be used to diagnose bacteriuria in women with limited
symptoms and signs (no more than two symptoms).
 Women with limited symptoms of UTI who have negative dipstick urinalysis (LE or
nitrite) should be offered empirical antibiotic treatment.
 The risks and benefits of empirical treatment should be discussed with the patient
and managed accordingly.
 If a woman remains symptomatic after a single course of treatment, she should be
investigated for other potential causes.
No robust evidence was identified describing LE or nitrite testing in elderly, institutionalised
patients.

In elderly patients (over 65 years of age), diagnosis should be based on a full clinical
assessment, including vital signs.
Management of suspected bacterial urinary tract infection in adults
2.3
Urine Culture
The quality of a urine sample will affect the ability to detect bacteria and confirm a diagnosis
of UTI. Specimens can be divided into those with high risk of contamination (clean catch or
midstream urine samples; MSU), or low risk (suprapubic aspirate; SPA or operatively obtained
urine from ureter or kidney). Standard laboratory processing of urine samples is confined to
a single initial specimen per patient, which detects conventional aerobic bacteria, normally
at a value of ≥105 cfu/ml. There is no bacterial count that can be taken as an absolute “gold
standard” for the diagnosis of UTI.
The criterion for the presence of significant bacteria was established from early work comparing
SPA against MSU specimens in women suffering either from acute UUTI or who had
asymptomatic UTI during pregnancy. A single positive MSU reliably determined the presence
of a UTI at 105 cfu/ml in 80% of cases studied with two samples improving this to 95%.62-64
For women experiencing symptoms of urinary tract infection lower numbers of colony
forming units may also reflect significant bacteria. A study comparing SPA against MSU
specimens found that the best diagnostic criterion in women was ≥102 cfu/ml (sensitivity 95%,
specificity 85%).65
The laboratory interpretation of a urine culture depends upon a combination of factors. These
include the number of isolates cultured and their predominance, the specimen type, the clinical
details, the presence or absence of pyuria and the numbers of organisms present. Conventional
laboratory practice in the UK detects aerobic bacteria at a value of ≥104 cfu/ml.22
2.4
antibiotic treatment
2.4.1symptomatic bacteriuria, LUTI
In a randomised controlled trial of non-pregnant women with dysuria, frequency or urgency and
positive LE tests but no symptoms or signs of UUTI and no significant comorbidity, 95% had
≥105 bacteria per ml of urine. Treatment with a single dose of either cefixime, co-trimoxazole
or ofloxacin was equally effective.66
1+
Another trial enrolled non-pregnant women aged 15-54 with dysuria and frequency, and
detected pyuria (method not specified) but no symptoms or signs of UUTI and no significant
comorbidity. A three day regimen of nitrofurantoin significantly shortened time to resolution
of symptoms.67
1++
A
Non-pregnant women with symptoms or signs of acute LUTI, and either high probability
of or proven bacteriuria, should be treated with antibiotics.
Three to six days of antibiotic treatment for uncomplicated LUTI in women aged 60 or over is
as effective as treatment for 7-14 days. 68,69
1++
Guidelines from the Infectious Diseases Society of America (IDSA)11 and Health Protection
Agency (HPA)55 recommend three days treatment with trimethoprim for LUTI. There is more
direct evidence for three days treatment with co-trimoxazole but it is reasonable to infer that
trimethoprim is equally effective as co-trimoxazole.11
1+
4
Three days of treatment with nitrofurantoin has been shown to be effective in non-pregnant
adult women with uncomplicated UTI.67 The IDSA recommends seven days treatment with
nitrofurantoin.11 There is no direct evidence comparing three days nitrofurantoin with seven
days nitrofurantoin.
1++
1+
B
Non-pregnant women of any age with symptoms or signs of acute LUTI should be
treated with trimethoprim or nitrofurantoin for three days.

Women with renal impairment should not be treated with nitrofurantoin as:
 an effective concentration of antibiotic in the urine is not achievable
 a toxic concentration of antibiotic can occur in the plasma.
2 MANAGEMENT OF BACTERIAL UTI IN ADULT WOMEN
Urinary pH affects the activity of nitrofurantoin. Nitrofurantoin is effective against E. coli at
a concentration of 100 mg/l as the concentration of antibiotic greatly exceeds the minimum
inhibitory concentration (MIC or lowest concentration of antibiotic that regularly inhibits growth
of the bacterium in vitro). The MIC increases twenty fold from pH5.5 to pH8.0 (see Table 4) 70
and at pH8.0 bacterial growth occurs with 25 mg/l of nitrofurantoin. A similar situation is seen
with P. mirabilis although it has a higher MIC than most strains of E. coli.
D
4
Women with LUTI, who are prescribed nitrofurantoin, should be advised not to take
alkalinising agents (such as potassium citrate).
Table 4: The effect of pH on the MIC of nitrofurantoin on E. coli and P. mirabilis70
Minimum inhibitory concentration of nitrofurantoin (mg/l)
pH 5.5
pH 7.0
pH 8.0
E. coli
2.5
10.0
50.0
P. mirabilis
15.0
50.0
100.0
Resistance is increasing to all of the antibiotics used to treat UTI and there is no clear first choice
alternative to trimethoprim or nitrofurantoin.11
1+
BPatients who do not respond to trimethoprim or nitrofurantoin should have urine taken
for culture to guide change of antibiotic.

Quinolones should not be used for empirical treatment of LUTI.
2.4.2symptomatic bacteriuria, UUTI
Upper urinary tract infection can be accompanied by bacteraemia, making it a life threatening
infection.11
Nitrofurantoin is an ineffective treatment for UUTI because it does not achieve effective
concentrations in the blood. Resistance to trimethoprim is too common to recommend this
drug for empirical treatment of a life threatening infection.55
4
One week of treatment with ciprofloxacin is as effective as two weeks treatment with cotrimoxazole.71
1++
A
Non-pregnant women with symptoms or signs of acute UUTI should be treated with
ciprofloxacin for seven days.
As resistance to quinolones is increasing, the HPA suggests that patients started on ciprofloxacin
should have urine sent for culture and that patients should be admitted to hospital if there is
no response to treatment within 24 hours.55
D
Urine should be taken for culture before immediate empirical treatment is started and
treatment changed if there is an inadequate response to the antibiotic.

Alternative treatments include co-trimoxazole, pivmecillinam, co-amoxiclav and
cefixime.
One week of treatment with pivmecillinam is less effective than two weeks treatment.11
4
1+
Evidence about the effectiveness of less than two weeks treatment with co-amoxiclav, cefixime
and co-trimoxazole is lacking.

Patients should be admitted to hospital if systemic symptoms appear.
Management of suspected bacterial urinary tract infection in adults
2.4.3
Asymptomatic bacteriuria
There is no evidence that treatment of asymptomatic bacteriuria in adult women significantly
reduces the risk of symptomatic episodes, either in women without comorbidity or with
underlying diabetes or primary biliary cirrhosis.20,72,73
1++
1+
In women with diabetes, antibiotic treatment of asymptomatic bacteriuria significantly increases
the risk of adverse events without significant clinical benefit, such as shortening duration of
symptoms.20
1+
A

Non-pregnant women with asymptomatic bacteriuria should not receive antibiotic
treatment.
In elderly women (over 65 years of age), treatment of asymptomatic bacteriuria does not
reduce mortality or significantly reduce symptomatic episodes. 19,74 Antibiotic treatment
significantly increases the risk of adverse events, such as rashes and gastrointestinal symptoms
(number needed to harm; NNTH 3; confidence interval; CI 2 –10. For statistical methods see
supplementary material section S1).19
A
1+
Elderly women (over 65 years of age) with asymptomatic bacteriuria should not receive
antibiotic treatment.
2.5non-antibiotic treatment
Recurrent UTIs are a common and debilitating problem. Repeated or prolonged treatment with
antibiotics is likely to contribute to the problem of antimicrobial resistance. Effective alternatives
to antibiotics have the potential to improve public health.
Alternatives to antibiotics offer an opportunity for patients to self manage the prevention of
recurrent UTIs, which may improve their quality of life.
2.5.1cranberry products
Cranberry products (juice, tablets, capsules) are not regulated and the concentration of active
ingredients is not known. Concentrations may also fluctuate between batches of the same
product.
Most of the high strength preparations (tablet/capsule form) in the UK quote 200 mg of cranberry
extract, equivalent to 5,000 mg of fresh cranberries (25:1 concentration).

There is good evidence to support the effectiveness of cranberry products for preventing
symptomatic UTI in adult women with a history of recurrent UTI (NNT to prevent one
symptomatic infection in six months 6.4, CI 3.7-25.9.75 For statistical methods see supplementary
material section S1). The effectiveness of cranberry products in other patients is not known.
The optimal dose and route of administration has not been addressed.
1++
There has been no direct comparison between cranberry products and antibiotic prophylaxis for
preventing recurrent UTI. The NNTs for cranberry products are higher than for nightly antibiotic
prophylaxis for six months,76 or postcoital antibiotic prophylaxis for six months.77
A
Women with recurrent UTI should be advised to take cranberry products to reduce
the frequency of recurrence.

Women should be advised that cranberry capsules may be more convenient than juice
and that high strength capsules may be most effective.
There is no evidence to support the effectiveness of cranberry products for treating symptomatic
episodes of UTI.78
No serious adverse effects to cranberry products were reported, although the high drop out
rate in clinical trials suggests that long term treatment with cranberry products may not be well
tolerated. The mechanism of action of cranberry products is unclear.
10
1++
2 MANAGEMENT OF BACTERIAL UTI IN ADULT WOMEN
By 2003 the Committee on Safety of Medicines (CSM) received 12 reports of suspected
interactions involving warfarin and cranberry juice. In eight of these cases there was an increase
in International Normalized Ratio (INR) of the prothrombin time.79
4
In October 2004 the CSM advised that patients taking warfarin should avoid taking cranberry
products unless the health benefits are considered to outweigh any risks.

D
Patients taking warfarin should avoid taking cranberry products unless the health benefits
are considered to outweigh any risks.

Increased medical supervision and INR monitoring should be considered for any patient
taking warfarin with a regular intake of cranberry products.
One clinical trial addressed the cost effectiveness of cranberry products for preventing UTI in
non-pregnant women (see supplementary material section S4.1).80

2.5.2
Women with recurrent UTI should be advised that cranberry products are not available
on the NHS, but are readily available from pharmacies, health food shops, herbalists
and supermarkets.
methenamine hippurate
A systematic review of methenamine hippurate identified considerable heterogeneity between
trials and concluded that interpretation of these data should be done cautiously, due to the
small sample sizes and poor methodology of the studies involved.81
Methenamine hippurate may be effective at preventing UTI in patients without known upper
renal tract abnormalities. Adverse events caused by methenamine were rare.81
1++
Two trials show that methenamine is less effective at preventing symptomatic UTI than nightly
prophylaxis with either nitrofurantoin or trimethoprim.82
1++
B
2.5.3
Methenamine hippurate may be used to prevent symptomatic UTI in patients without
known upper renal tract abnormalities.
oestrogen
Genitourinary atrophy may increase the risk of bacteriuria and the role of oestrogen therapy in
reducing the risk of symptomatic UTI has been investigated.
Evidence for the efficacy of oestrogen in comparison with placebo is inconsistent. There is good
evidence that this treatment is less effective than antibiotic prophylaxis.83 A trial comparing
nine months treatment with oral nitrofurantoin versus estriol pessaries in post menopausal
women reported a significantly reduced risk of symptomatic UTI with nitrofurantoin.83 Two
systematic reviews of vaginal oestrogen administration both reported considerable unexplained
heterogeneity of results with some studies reporting significant reduction in risk of recurrent
UTI while others report no significant effect or even a trend towards harmful effects.84,85
A
1++
1+
Oestrogens are not recommended for routine prevention of recurrent UTI in
postmenopausal women.
Treatment with oestrogens may be appropriate for some women.
2.5.4analgesia
No evidence was found for the use of analgesics for symptomatic relief of uncomplicated
UTIs.

Women with uncomplicated UTIs may wish to use over the counter remedies to try and
relieve symptoms.
11
Management of suspected bacterial urinary tract infection in adults
2.6referral
Recurrent UTI is a common reason for referral of women to urologists but no evidence was
found describing criteria for referral or about which investigations to undertake.
There is good evidence to support prevention of recurrent bacterial UTI in women with
antibiotics82 and cranberry products (see section 2.5.1). These strategies should be explored
before referral for specialist investigation.
2.7cost-effective treatment in primary care
There are two key issues in the economic evaluation of strategies for managing
suspected UTI:


2.7.1
Antibiotics account for only 13% of the total primary care costs for patients with lower
urinary tract infection and only 2-8% of the costs for patients with upper urinary tract
infection. Visits to the GP account for the majority of costs.86
Management strategies that minimise healthcare costs may transfer costs to the patient.
A decision analysis of management strategies for acute uncomplicated lower urinary tract
infection in primary care concluded that empiric antibiotic treatment without urine culture
was the preferred strategy.87 This strategy, however, prolongs the average duration of
symptoms because it takes longer to identify women whose infections are caused by antibiotic
resistant bacteria.86
GP Consultation
Three decision analyses comparing empiric antibiotic treatment with or without urine culture
concluded that taking a urine culture routinely for all patients will cost more but is likely to
reduce symptom days by between 0.04 and 0.32 days.87-89 This is achieved through a combination
of reducing risk of adverse effects, by stopping treatment if the culture is negative and early
identification of infections caused by antibiotic resistant bacteria. There is considerable variation
in the estimates of the incremental cost effectiveness of urine culture.
One study estimated the cost per symptom day prevented as £215.89 The estimated cost per QALY
(quality adjusted life year) gained was £215,000.89 It is unlikely that routine culture of urine will
be cost effective unless the prevalence of bacteriuria in symptomatic women is <30%.89 This is
well below the lowest figure reported in epidemiology studies (see Table 1).
Dipstick testing was shown to save fewer symptom days at greater cost than urine culture.88,89
Dipstick strategies only became cost effective if both the sensitivity of the test and the risk of
antibiotic side effects were maximised to unrealistic levels.88,89 Dipstick testing is only likely to be
cost effective in symptomatic women with low probability of bacteriuria (<50%, for example,
with only one symptom) and urine culture is only likely to be cost effective in women with very
low probability (<20%, for example, with only one symptom and negative dipstick test).
2.7.2
Telephone Consultation
Evidence from a controlled before and after study (CBA) and an RCT showed that telephone
consultation by nurse practitioners is as effective and safe as standard consultation in a medical
practitioner’s office, is preferred by a majority of women and is likely to be cost saving.15,90
Implementation of telephone consultation in an American population with 147,000 women
aged 18 to 55 years was estimated to save one health plan $367,000 per year.15 There was a
marked trend towards increase in return visits for STDs (relative risk of return visit for STD after
nurse telephone consultation 1.79, CI 0.92-3.50).15
Although telephone consultation and antibiotic prescribing by nurse practitioners could be a costeffective alternative to a general practitioner visit it goes against one of four key recommendations
made to primary care by the Department of Health: Standing Medical Advisory Committee, which
was to “limit antibiotic prescribing over the telephone”.91 The available evidence also raises
serious questions about the safety of telephone consultations for excluding STDs. Telephone
consultation cannot be recommended as an alternative to a standard consultation.
12
3 MANAGEMENT OF BACTERIAL UTI IN PREGNANT WOMEN
3
Management of bacterial UTI in pregnant
women
The management of symptomatic bacterial UTI in pregnant women is summarised in Annex 3.
3.1diagnosis
3.1.1
Symptomatic bacteriuria
Symptomatic bacteriuria occurs in 17–20% of pregnancies.25 There are pathophysiological
grounds to support a link to pre-labour, premature rupture of membranes (PPROM) and pre-term
labour.92 Untreated upper urinary tract infection in pregnancy also carries well documented
risks of morbidity, and rarely, mortality to the pregnant woman.92
Two to nine percent of pregnant women are bacteriuric in the first trimester, a similar prevalence
to non-pregnant women of the same age.21,93 10-30% of women with bacteriuria in the first
trimester develop upper urinary tract infection in the second or third trimester.
3.1.2the gold standard for diagnosis in pregnancy

The gold standard method for diagnosis of bacteriuria is culture of urine obtained by suprapubic
needle aspiration. A catheter specimen of urine is less reliable than suprapubic needle aspiration,
although more reliable than two MSU samples.94 Many studies report using single MSU samples.
In women with acute symptoms of UTI the presence of ≥105 bacteria per ml of a single MSU
sample has about 80% specificity in comparison with the gold standard while a single specimen
(MSU or CSU) has a false positive rate of up to 40% for diagnosis of asymptomatic bacteriuria
in pregnancy (see supplementary material section S3.1).94,95
3.1.3near patient testing
A systematic review of studies comparing urine culture with near patient tests reported that
no studies used the gold standard for diagnosis of asymptomatic bacteriuria in pregnancy.92 In
the only study to establish the diagnosis of bacteriuria with two consecutive urine samples at
the first antenatal visit, 8.3% of pregnant women had asymptomatic bacteriuria while 12.1%
had a positive dipstick test with sensitivity and specificity of 92.0% and 95.0%.96 Five false
negative dipstick tests were for patients who had bacteriuria with gram-positive bacteria (three
group B streptococci and two enterococci) which do not cause upper UTI, but are implicated
in causing premature delivery.
1+
Dipstick testing (LE or nitrate) is not sufficiently sensitive to be used as a screening test. Urine
culture should be the investigation of choice.
A
Standard quantitative urine culture should be performed routinely at first antenatal
visit.
A
The presence of bacteriuria in urine should be confirmed with a second urine
culture.
A
Dipstick testing should not be used to screen for bacterial UTI at first or subsequent
antenatal visits.

Dipsticks to test only for proteinuria and the presence of glucose in the urine should be
used for screening at the first and subsequent antenatal visits as a more cost-effective
alternative to multi-reagent dipsticks that detect the presence of nitrite, leucocyte esterase
and blood in addition to protein and glucose.
13
Management of suspected bacterial urinary tract infection in adults
3.2
antibiotic treatment
RCTs addressing treatment of UTI in pregnant women frequently include patients with
asymptomatic bacteriuria and symptomatic bacteriuria, upper and lower UTI. There is often
poor definition of long term outcomes.
3.2.1
Symptomatic bacteriuria
In pregnant women with symptoms of both UUTI and LUTI there is evidence that a range of
antibiotic regimens achieve cure.97-101 There is no clear evidence of benefit by reduction of long
term renal damage or pre-term labour as most studies are heterogeneous with respect to LUTI
and UUTI and did not specifically address these outcomes.
1++
1+
2+
There is no clear evidence that any particular antibiotic or dosage regimen has any advantage.25
None of the studies addressed the risk of treatment, but apart from the hazards of adverse
reactions or anaphylaxis caused by an inappropriate antibiotic, the risks are likely to be small
compared to the proven benefit.25
1+
BPregnant women with symptomatic UTI should be treated with an antibiotic.

A single urine sample should be taken for culture before empiric antibiotic treatment is
started.
Nitrofurantoin is not an effective treatment for UUTI because it does not achieve effective
concentrations in the blood.55
3.2.2


Refer to local guidance for the safest, cheapest, effective antibiotic for pregnant
women.

Given some antibiotics are toxic in pregnancy, refer to the British National Formulary
(BNF) for contraindications.

Given the risks of symptomatic bacteriuria in pregnancy, a urine culture should be
performed seven days after completion of antibiotic treatment as a test of cure.
ASymptomatic bacteriuria
A systematic review concluded that antibiotic treatment of asymptomatic bacteriuria in pregnancy
reduces the risk of upper urinary tract infection, pre-term delivery and low birth weight babies
(see supplementary material section S3.1).102
Most of the trials in this review were of continuous antibiotic therapy from diagnosis of
asymptomatic bacteriuria until the end of pregnancy.102 This is not standard care in the NHS in
Scotland, where asymptomatic bacteriuria is usually treated with a short course (3-7 days) of
antibiotics. The evidence suggests that 3-7 days treatment is as effective as continuous antibiotic
therapy.102
There is insufficient evidence to compare the effectiveness of single dose treatment with a 3-7
day course103 or a three day with a seven day course.
AAsymptomatic bacteriuria detected during pregnancy should be treated with an
antibiotic.
Refer to local guidance for the safest, cheapest, effective antibiotic for pregnant
women.
There is no need for empirical treatment in this group of patients as all women have urine culture
before treatment.
The benefits and risks of antibiotic treatment of symptomatic bacteriuria in pregnant women
apply equally to pregnant women with asymptomatic bacteriuria.
14
4
1++
3 MANAGEMENT OF BACTERIAL UTI IN PREGNANT WOMEN
3.3
Screening during pregnancy
A large observational study demonstrated the effectiveness of a screening programme
based on diagnosis of asymptomatic bacteriuria with two urine cultures in the first trimester
(see Figure 2).95
2+
Figure 2: Frequency of asymptomatic bacteriuria, response to treatment and subsequent
development of upper urinary tract infection. Adapted from Gratacos et al 1994.95
Screening
n=1,652
Positive
n=144
10 not repeated
& (57 not)
con�rmed
Con�rmed
n=77
Treated
n=70
UUTI (No)
C
n=1575
Not treated
n=7
Eradication
n=53 (75%)
Recurrence
n=6 (8%)
Failure
n=11 (16%)
2
0
0
Treated
bacteriuric:
2.8% UUTI
Negative
n=1508
2
5
Untreated
bacteriuric:
28% UUTI
Nonbacteriuric:
0.31% UUTI
Women with bacteriuria confirmed by a second urine culture should be treated and
have repeat urine culture at each antenatal visit until delivery.
 Women who do not have bacteriuria in the first trimester should not have repeat urine
cultures.

There is inconsistent evidence regarding the cost effectiveness of screening pregnant women
for asymptomatic bacteriuria (see supplementary material section S4.2).92,95,104-106
15
Management of suspected bacterial urinary tract infection in adults
4
Management of bacterial UTI in adult men
The management of symptomatic bacterial UTI in men is summarised in Annex 4.
4.1diagnosis
Urinary tract infections in men are generally viewed as complicated because they result from
an anatomic or functional anomaly or instrumentation of the genitourinary tract.107
Conditions like prostatitis, chlamydial infection and epididymitis should be considered in the
differential diagnosis of men with acute dysuria or frequency and appropriate diagnostic tests
should be considered.
There is no evidence to suggest the best method of diagnosing bacterial UTI in men. Evidence
from studies of women cannot be extrapolated.

Urine microscopy should not be undertaken in clinical settings in primary or secondary
care.

In all men with symptoms of UTI a urine sample should be taken for culture.

In patients with a history of fever or back pain the possibility of UUTI should be considered
and urine culture should guide the choice of antibiotic.
Obtaining a clean-catch sample of urine in men is easier than in women and a colony count
of ≥103 cfu/ml may be sufficient to diagnose UTI in a man with signs and symptoms as long
as 80% of the growth is of one organism.108
3
A threshold of ≥103 cfu/ml for diagnosing UTI is below the threshold of detection for some
commonly used laboratory methods, which only detect between 104 and 105 cfu/ml.

Methods for detecting lower levels of bacteria in urine samples should be developed
and implemented.
The culture of expressed prostatic secretion and semen has no clinical benefit and is no longer
common practice.109
4.2Antibiotic Treatment
No high quality evidence for the treatment of bacterial UTI in men was identified.
At least 50% of men with recurrent UTI110 and over 90% of men with febrile UTI111 have
prostate involvement, which may lead to complications such as prostatic abscess or chronic
bacterial prostatitis.
16
4
4 MANAGEMENT OF BACTERIAL UTI IN ADULT MEN
4.2.1symptomatic bacteriuria
Given the difficulty of excluding prostatitis in men with symptoms suggestive of UTI, the current
standard of care is a two week course of antibiotic likely to be effective for prostatitis.111 Due to
their ability to penetrate prostatic fluid, quinolones rather than nitrofurantoin or cephalosporins
are indicated. A two week course of treatment was shown to be as effective as a four week course
for patients with febrile UTI.111
C
Bacterial UTI in men should be treated empirically with a two week course of
quinolone.

Alternative treatments include trimethoprim, deoxycycline and co-amoxiclav.
2+
Evidence about the effectiveness of treatment with trimethoprim, deoxycycline and co-amoxiclav
is lacking.

4.2.2

Patients who do not respond to antibiotic treatment should be investigated for
prostatitis.
Asymptomatic bacteriuria
In elderly men (over 65 years of age), treatment of asymptomatic bacteriuria does not reduce
mortality or significantly reduce symptomatic episodes.19,74 Antibiotic treatment significantly
increases the risk of adverse events, such as rashes and gastrointestinal symptoms (NNTH 3;
CI 2 - 10.19 For statistical methods see supplementary material section S1).
A
1+
Elderly men (over 65 years of age) with asymptomatic bacteriuria should not receive
antibiotic treatment.
4.3referral
Recurrent UTI is a common reason for referral to urologists. There are no trials about the
effectiveness of antibiotics or cranberry products for preventing recurrent UTI in men. There are
no evidence based guidelines for referral or about which investigations to undertake.
Expert opinion suggests that men should be investigated if they have symptoms of upper urinary
tract infection, fail to respond to appropriate antibiotics or have recurrent UTI (two or more
episodes in three months).112
D
Men should be referred for urological investigation if they have symptoms of upper
urinary tract infection, fail to respond to appropriate antibiotics or have recurrent
UTI.
Urodynamic techniques, such as pressure/flow videocystography revealed significant underlying
lower urinary tract abnormalities (mainly involving bladder outflow obstruction) in 80% of adult
males presenting with simple or recurrent urinary tract infections, but without prior urinary
symptoms or disorders.113

4
2+
Renal and post-void bladder ultrasound and a kidneys, ureters and bladder (KUB) plain
X-ray of the abdomen may be used to look for relevant abnormalities.
17
Management of suspected bacterial urinary tract infection in adults
5
Management of bacterial UTI in patients with
catheters
5.1
Diagnosis
Between 2% and 7% of patients with indwelling urethral catheters acquire bacteriuria each day,
even with the application of best practice for insertion and care of the catheter.114 All patients
with a long term indwelling catheter are bacteriuric, often with two or more organisms.115,116
The catheter provides a focus for bacterial biofilm formation. The majority of data comes from
studies in elderly patients with long term indwelling catheters. There is no evidence to suggest
that the prevalence in younger short or long term catheterised patients, such as those with
multiple sclerosis or spinal cord injury, is any different.117
Duration of catheterisation is strongly associated with the risk of infection. The longer the catheter
is in place the greater the likelihood of infection.118 Intermittent catheterisation is associated
with a lower incidence of asymptomatic bacteriuria.117
The presence of a short or long term indwelling catheter is associated with a greater incidence
of fever of urinary tract origin. Fever without any localising signs is a common occurrence
in catheterised patients and urinary tract infection accounts for about a third of these
episodes.117,119,120 In patients with short or long term catheters fever is associated with a higher
occurrence of local urinary tract and systemic complications such as bacteraemia.117,119,121,122
Although mortality appears to be higher in patients with long term indwelling catheters, there
is no causative link with catheterisation or urinary tract infection.123
Urinary tract infection is the most common hospital acquired infection in the UK, accounting
for 23% of all infections and the majority of these are associated with catheters.124 Catheter
associated UTI is the source for 8% of hospital acquired bacteraemia.125
In catheterised patients the common occurrence of fever, the consistent presence of bacteriuria,
and the variable presence of a broad range of other associated clinical manifestations (new onset
confusion, renal angle tenderness or suprapubic pain, chills/rigors etc) makes the diagnosis of
symptomatic UTI difficult.24,126,127
Current suggested criteria for diagnosing UTI in catheterised patients are not evidence based.126
A clinical algorithm for suspected UTI in catheterised and non-catheterised residents in nursing
homes suggests that the presence of one of the following symptoms should stimulate antibiotic
therapy:128




new costovertebral tenderness
rigors
new onset delirium
fever greater than 37.9°C or 1.5°C above baseline on two occasions during 12 hours.
No particular constellation of symptoms or clinical signs, for example, fever or chills, new flank
or suprapubic tenderness, change in character of urine or worsening of mental or functional
status, appears to increase the likelihood of a symptomatic urinary tract infection in catheterised
patients. The positive predictive value (PPV) of bacteriuria for febrile urinary tract infection
identified by clinical criteria has been measured as 11%.119 The most common symptom, fever,
is a non-specific presenting symptom in symptomatic urinary tract infection.117,119,121 The absence
of fever does not appear to exclude urinary tract infection.
D Clinical symptoms or signs are not recommended for predicting the likelihood of
symptomatic UTI in catheterised patients.
18
1++
3
5 MANAGEMENT OF BACTERIAL UTI IN PATIENTS WITH CATHETERS

In catheterised patients who present with fever:
 look for associated localising (loin or suprapubic tenderness) or systemic features
 exclude other potential sources of infection
 send off an appropriately taken urine sample for culture to determine the infecting
organism and susceptibilities
 consider antibiotic therapy taking into account the severity of the presentation and
any comorbid factors.

Urine samples should only be sent for laboratory culture if the patient has clinical sepsis,
not because the appearance or smell of the urine suggests that bacteriuria is present.
5.2near patient testing
5.2.1urine microscopy
The value of microscopy of urine samples from catheterised patients is limited in diagnosing
symptomatic UTI as all patients will have bacteriuria. There is no relationship between the level
of pyuria and infection in patients with indwelling catheters, since the presence of the catheter
invariably induces pyuria without the presence of infection.129
2+
CLaboratory microscopy should not be used to diagnose UTI in catheterised patients.
5.2.2dipstick tests
Symptomatic UTI cannot be differentiated from asymptomatic bacteriuria on the basis of urine
analysis with dipstick tests. Pyuria is common in catheterised patients and its level has no
predictive value.129,130
There is no evidence to suggest that detecting pyuria by urine analysis is of any value
in differentiating symptomatic UTI from asymptomatic UTI (bacteriuria) in catheterised
patients.129-131
B
5.3
2++
2+
3
Dipstick testing should not be used to diagnose UTI in catheterised patients.
antibiotic Prophylaxis to Prevent Catheter Related UTI
A meta-analysis of antimicrobial prophylaxis for UTI in catheterised patients with spinal cord
dysfunction included patients with acute (less than 90 days after spinal cord injury) and nonacute (greater than 90 days after spinal cord injury) spinal cord dysfunction and neurogenic
bladder.132 The majority of patients had intermittent catheterisation. Antimicrobial prophylaxis
did not significantly decrease symptomatic infections. Prophylaxis was associated with the
reduction of asymptomatic bacteriuria among acute patients (p<0.05). There was no significant
reduction among non-acute patients. On average 3.57 weeks of treatment were required to
prevent one episode of asymptomatic bacteriuria in a patient with acute spinal cord injury.
Overall there was an approximately twofold increase in antimicrobial resistant bacteria except
in the group who received methenamine.
1++
1+
This agrees with a systematic review of antibiotic prophylaxis in multiple sclerosis and spinal
cord injury patients with neurogenic bladder.117
AAntibiotic prophylaxis is not recommended for the prevention of symptomatic UTI in
catheterised patients.

Antimicrobial prophylaxis may be considered in patients for whom the number of
infections are of such frequency or severity that they chronically impinge on function
and well-being.
 Antibiotic prophylaxis in catheterised patients may reduce the occurrence of
asymptomatic bacteriuria but at the risk of increasing antibiotic resistance.
19
Management of suspected bacterial urinary tract infection in adults
5.4
antibiotic treatment
5.4.1symptomatic bacteriuria
Symptoms that may suggest UTI in patients with catheters include fever, flank or suprapubic
discomfort, change in voiding patterns, nausea, vomiting, malaise or confusion.126,128
No studies were identified that evaluated the prognostic value of individual or combinations of
signs or symptoms, with the exception of fever. The occurrence of febrile episodes in patients
with long term indwelling catheters is associated with the development of abnormalities such
as calculi and complications in the kidney.133
1+
Evidence for antibiotic treatment of symptomatic UUTI in non-pregnant women is applicable
to catheterised patients with symptomatic UTI and has been extrapolated to give the following
good practice points (see section 2.4.2).

Catheterised patients with symptoms or signs of acute UUTI should be treated with
ciprofloxacin or co-amoxiclav for seven days.

Patients should be admitted to hospital if systemic symptoms, such as fever, rigors, chills,
vomiting or confusion appear.
Patients with long term indwelling catheters, who have the catheter changed before starting
antibiotic treatment for symptomatic UTI, have a decreased duration of fever, are more likely to
be cured or improved after three days and are less likely to have recurrence of acute symptoms
within one month of treatment.134
1+
BPatients with long term indwelling catheters should have the catheter changed before
starting antibiotic treatment for symptomatic UTI.

5.4.2


Urine should be taken for culture before the catheter is changed and treatment is started.
Treatment should be changed if the organism is resistant to the chosen antibiotic.
ASymptomatic bacteriuria
Single dose antibiotic treatment of women with asymptomatic bacteriuria after short term
catheterisation significantly reduces the risk of symptomatic episodes in the subsequent
two weeks (number needed to benefit; NNTB 7, CI 4-25.20 For statistical methods see
supplementary material section S1). Given that the prevalence of bacteriuria should be
<20%,135 this means that over 100 women may need to be screened to prevent one
symptomatic episode through treatment. Several studies addressed the cost effectiveness of
screening for asymptomatic bacteriuria in catheterised patients (see supplementary material
section S4.3). 89,135-137
B
Screening of women with asymptomatic bacteriuria after short term catheterisation
is not recommended.
There is inconsistent evidence of benefit from repeated treatment of asymptomatic bacteriuria
in patients with long term catheters.115,138,139
There is evidence that repeated treatment of asymptomatic bacteriuria increases the risk of
colonisation by drug resistant bacteria.139
B
20
1+
Catheterised patients with asymptomatic bacteriuria should not receive antibiotic
treatment.
1++
1+
11++
5 MANAGEMENT OF BACTERIAL UTI IN PATIENTS WITH CATHETERS
5.5management of bacterial uti in patients with urinary stomas
There is no evidence to support the management of bacterial UTI in patients with urinary stomas
but issues that affect catheterised patients are likely to apply. The prevalence of bacteriuria is
likely to be 100% in patients with urinary stomas. Culture of urine from patients with symptoms
suggestive of UTI should only be carried out to test the susceptibility of potential pathogens.

Urine samples should only be sent for laboratory culture if the patient has clinical sepsis,
not because the appearance or smell of the urine suggests that bacteriuria is present.
21
Management of suspected bacterial urinary tract infection in adults
6
Information for discussion with patients and
carers
6.1notes for discussion with patients and carers
The following points were drawn up by the guideline development group to reflect the issues
most likely to be of concern to patients and carers following a diagnosis of suspected bacterial
urinary tract infection in adult non-pregnant women. These points are provided for use by health
professionals when discussing bacterial UTI with patients and in guiding the production of locally
produced patient information materials.
6.2
Key issues






There is a need to balance the accuracy of a diagnosis with the speed in which results
(and treatment, if necessary) are delivered to the patient. Patients get very frustrated waiting
for “official” results to merit treatment of a painful, uncomfortable situation that is preventing
normal daily activities.
Many professionals are interested in the accuracy of the assessment, in order not to prescribe
inappropriate or unnecessary treatment, which can prolong symptoms.
Patients are aware that dipsticks are not always accurate and that waiting for laboratory
analysis can delay time to diagnosis and treatment.
Patients know that factors such as their mood and communication of discomfort also are
important in signalling infection.
Patients perceive that the best healthcare professionals are those who consider the factors
that the patient finds signal infection.
Many patients want information and clear explanation of questions such as:
‘Why doesn’t this treatment seem to be working?’
‘How long until I feel better?’
‘Can something alleviate my symptoms (and pain!) in the meantime, or at least ensure a level
of comfort so that I can resume normal daily activities (for example, go to work, sleep at
night)?’
‘What could happen if I don’t comply fully (for example, if I forget to take the full course of
treatment)?’
‘Will this drug react/interact with any other drugs/medicines/herbal medicines I am taking?’
6.3general advice
Healthcare professionals should offer:




22
information on cranberries. Patients should be advised that further research is required to
determine the best way to take cranberries, for example, juice, tablets, or a combination;
in what concentration; routinely or preventatively; and how often (see section 2.5.1).
advice on “complicated” versus “uncomplicated” infections. The distinction between a
3-day versus a 7-day course of pills and the reasons for using one or the other should also
be explained to the patient. These issues could affect concordance.
contraception advice. This and the role of sexual activity is a critical issue for women, and
one which may affect concordance. This issue should be explicitly dealt with by healthcare
professionals prescribing and dispensing treatment.
a reminder to patients and carers that the presence of bacteriuria does not always indicate
disease. Especially in elderly patients, asymptomatic bacteriuria is a normal condition and
should not be treated with antibiotics.
6 INFORMATION FOR DISCUSSION WITH PATIENTS AND CARERS
Given that there is no conclusive association between lifestyle factors, such as diet, hydration,
clothing, toileting activity and sexual activity, and susceptibility to bacterial UTI in adult,
non-pregnant women, there is no evidence to support healthcare professionals giving routine
advice to patients about lifestyle factors.140-143 There may be a link between second UTI and
sexual activity.140

Routine advice about adopting or discontinuing any particular lifestyle factors should
not be offered to patients with bacterial UTI.

For an individual with recurrent and/or complicated urinary tract infection, healthcare
professionals may wish to discuss the features of the patient’s own situation which may
particularly contribute to the problem.
6.4sources of further information for patients and carers
Age Concern Scotland
13 Rose Street, Edinburgh EH2 3DT
Tel: 0131 220 3345 • Freephone information line: 0800 00 99 66
Website: www.ageconcernscotland.org.uk
Association for Continence Advice
Mr Jim Torrance, Chairman ACA Scotland, Borders Primary Care NHS Trust
Nursing Services, Dingleton Hospital, Melrose, Selkirkshire TD6 9HN
Tel: 01896 750027 • Fax: 01896 759491
A national organisation working towards raising standards of continence care with many
professional members offering advice and treatment.
Bladder Pain Syndrome Association
54 Sutherland Road, Belvedere, Kent DA17 6JR
Tel: 0208 310 8729
Website: www.b-p-s-a.org.uk
Provides information and support to sufferers of bladder pain syndromes (including interstitial
cystitis and other related disorders/syndromes).
Continence Foundation
307 Hatton Square, 16 Baldwins Gardens, London EC1N 7RJ
Tel: 020 7404 6875 • Helpline: 020 7831 9831 • Fax: 020 7404 6876
Email: [email protected] • Website: www.continence-foundation.org.uk
Offers expert advice to people with bladder and bowel problems, their carers and professionals
in the field. The nurses who run the helpline also have details of all incontinence advice services
and of all products on the UK market.
Cystitis and Overactive Bladder Foundation
76 High Street, Stony Stratford, Buckinghamshire MK11 1AH
Tel: 0190 856 9169
Website: www.cobfoundation.org
Provides information, leaflets and support to people with all forms of lower urinary tract infection
and overactive bladders.
Family Planning and Reproductive Health Care
The Sandyford Initiative, 6 Sandyford Place, Sauchiehall Street, Glasgow G3 7NB
Tel: 0141 211 8600
Family Planning Association Scotland
Unit 10, Firhill Business Centre, 76 Firhill Road, Glasgow G20 7BA
Tel: 0141 576 5088 • Helpline: 0141 576 5088
(Monday to Thursday 9am - 5pm, Friday 9am - 4.30pm)
23
Management of suspected bacterial urinary tract infection in adults
Incontact (National Action on Incontinence)
Ms Cathy McKerrell, Project Manager (Scotland), 31 Brownshill Avenue,
Coatbridge, Lanarkshire ML5 5JF
Tel: 0870 770 3248 • Fax 0870 770 3248
Email: [email protected] • Website: www.incontact.org
Aims to provide information and support to people affected by bladder and bowel continence
problems, to increase awareness about incontinence difficulties and encourage those affected
to seek professional help.
National Childbirth Trust
Alexandra House, Oldham Terrace, Acton, London W3 6NH
Tel: 0870 7703236 • Enquiry Line: 0870 444 8707 • Fax: 0870 770 3237
Email: [email protected] • Website: www.nctpregnancyandbabycare.com
National Kidney Federation
Helpline: 0845 601 02 09
A charity run by kidney patients for kidney patients, it provides patient support services to
patients and their families.
NHS24
Tel: 0854 24 24 24 • Textphone: 18001 0854 24 24 24
Website: www.nhs24.com
NHS 24 is a nurse-led helpline providing confidential healthcare advice and information.
PRODIGY
Website: www.prodigy.nhs.uk
A source of evidence based clinical knowledge about the common conditions and symptoms
managed by primary healthcare professionals. Patient information leaflets form an integral part
of PRODIGY.
Urostomy Association
Hazel Pixley, National Secretary, Central Office, 18 Foxglove Avenue, Uttoxeter,
Staffordshire ST14 8UN
Tel: 0870 770 7931 • Fax: 0870 770 7932
Email: [email protected] • Website: www.uagbi.org
Women’s Health Concern Ltd.
Whitehall House, 41 Whitehall, London SW1A 2BY
Tel: 020 7451 1377
Email: [email protected] • Website: www.womens-health-concern.org
Women’s Health
52 Featherstone Street, London EC1Y 8RT
Helpline: 020 7251 6333 (9.30am –1.30pm weekdays) • Fax: 020 7250 4152
Email: [email protected][email protected]
Website: www.womenshealthlondon.org.uk
24
7 RECOMMENDATIONS FOR IMPLEMENTATION, AUDIT, SURVEILLANCE AND RESEARCH
7
Recommendations for implementation, audit,
surveillance and research
7.1
local implementation
Implementation of national clinical guidelines is the responsibility of local NHS organisations
and is an essential part of clinical governance. It is acknowledged that not every guideline can
be implemented immediately on publication, but mechanisms should be in place to ensure that
the care provided is reviewed against the guideline recommendations and the reasons for any
differences assessed and, where appropriate, addressed. These discussions should involve both
clinical staff and management. Local arrangements may then be made to implement the national
guideline in individual hospitals, units and general practices, and to monitor compliance. This
may be done by a variety of means including patient-specific reminders, continuing education
and training, and clinical audit. Implementing the new general practice contract will provide
opportunities to introduce such elements of good practice.
7.2
Key areas for Audit
7.2.1
KEY AREAS FOR audit in primary care
The management of patients with acute urinary symptoms should be audited against the
appropriate algorithm (see Annexes 1 to 4).
7.2.2
KEY AREAS FOR audit in secondary care


7.3
Audit of clinical evidence of infection in patients with long term catheters who have been
treated with antibiotics or had catheter urine samples sent for culture.
Audit of elderly patients (typically confused, with a cough, who are positive for nitrite in
the urine) treated with augmentin or equivalent and frusemide (so called elderly “coamilofrus”
regimen) with no documented evidence of symptoms of UUTI or LUTI.
Implementation and Audit of the recommendations
7.3.1Management of bacterial UTI in adult women
Recommendation
2.1 C
In otherwise healthy women presenting
with symptoms or signs of UTI, empirical
treatment with an antibiotic should be
considered.
2.1 C
In women with symptoms of vaginal itch or
discharge, explore alternative diagnoses and
consider pelvic examination.
2.1 
In patients presenting with symptoms or
signs of UTI who have a history of fever or
back pain the possibility of UUTI should
be considered. Empirical treatment with an
antibiotic should be started and urine culture
performed to guide the choice of antibiotic.
2.2.2 
Urine microscopy should not be undertaken
in clinical settings in primary or secondary
care.
Implementation or audit
Implementation of care pathways in
primary and secondary care including
minimum data to be recorded in
assessing a woman with symptoms of
LUTI.
Audit of practice against care pathway.
Environmental infection control audits
in primary and secondary care should
ensure that urine microscopy is not
being undertaken.
25
Management of suspected bacterial urinary tract infection in adults
Recommendation
2.2.3 B
Dipstick tests should only be used to
diagnose bacteriuria in women with limited
symptoms and signs (no more than two
symptoms).
2.2.3 B
Women with limited symptoms of UTI who
have negative dipstick urinalysis (LE or
nitrite) should be offered empirical antibiotic
treatment.
2.2.3 B
The risks and benefits of empirical treatment
should be discussed with the patient and
managed accordingly.
2.2.3 B
If a woman remains symptomatic after a
single course of treatment, she should be
investigated for other potential causes.
2.2.3 
In elderly patients (over 65 years of age),
diagnosis should be based on a full clinical
assessment, including vital signs.
2.4.1 A
Non-pregnant women with symptoms
or signs of acute LUTI and either high
probability of or proven bacteriuria should
be treated with antibiotics.
2.4.1 B
Non-pregnant women of any age with
symptoms or signs of acute LUTI should be
treated with trimethoprim or nitrofurantoin
for three days.
Implementation or audit
Implementation of care pathways in
primary and secondary care including
minimum data to be recorded in
assessing a woman with symptoms of
LUTI.
Audit of practice against care pathway
Measurement of length of treatment
with trimethoprim or nitrofurantoin
on “PRISMS for Practices” project,
comparison of local practices’
percentage of three day courses with
national data.
Percentage of prescribed courses of
trimethoprim or nitrofurantoin for LUTI
that are for three days
2.4.1 B
Patients who do not respond to trimethoprim
or nitrofurantoin should have urine taken for
culture to guide change of antibiotic.
Audit of management of patients
with repeat visits within 28 days of
prescription of trimethoprim for LUTI.
2.4.1 
Quinolones should not be used for empirical
treatment of LUTI.
Percentage of LUTI treated with
quinolones with no prior episode of
UTI in the past 28 days and no urine
culture sent.
2.4.2 A
Non-pregnant women with symptoms or
signs of acute UUTI should be treated with
ciprofloxacin for seven days.
2.4.2 D
Urine should be taken for culture before
immediate empirical treatment is started and
treatment changed if there is an inadequate
response to the antibiotic.
2.4.3 A
Non-pregnant women with asymptomatic
bacteriuria should not receive antibiotic
treatment.
2.4.3 A
26
Elderly women (over 65 years of age) with
asymptomatic bacteriuria should not receive
antibiotic treatment.
Implementation of care pathway
for UUTI in primary and secondary
care with audit of practice against
recommendations.
Percentage of women treated in
secondary care for “UTI” with no
documented evidence of symptoms of
UUTI or LUTI.
7 RECOMMENDATIONS FOR IMPLEMENTATION, AUDIT, SURVEILLANCE AND RESEARCH
7.3.2MANAGEMENT OF BACTERIAL UTI IN PREGNANT WOMEN
Recommendation
3.1.3 A
3.1.3 A
The presence of bacteriuria in urine should
be confirmed with a second urine culture.
3.1.3 A
Dipstick testing should not be used to screen for
bacterial UTI at first or subsequent antenatal
visits.
3.1.3 
Dipsticks to test only for proteinuria and the
presence of glucose in the urine should be
used for screening at the first and subsequent
antenatal visits as a more cost-effective
alternative to multi-reagent dipsticks that
detect the presence of nitrite, leucocyte
esterase and blood in addition to protein and
glucose.
3.2.1 B
Pregnant women with symptomatic UTI
should be treated with an antibiotic.
3.2.1 
Given some antibiotics are toxic in pregnancy,
refer to the British National Formulary (BNF)
for contraindications.
3.2.1 
A single urine sample should be taken for
culture before empiric antibiotic treatment is
started.
3.2.1 
Given the risks of symptomatic bacteriuria
in pregnancy, a urine culture should be
performed seven days after completion of
antibiotic treatment as a test of cure.
3.2.1 
Refer to local guidance for the safest,
cheapest, effective antibiotic for pregnant
women.
and
3.2.2
3.2.2 A
Implementation or audit
Standard quantitative urine culture should be
performed routinely at first antenatal visit
Care pathway for detection and
management of asymptomatic
bacteriuria of pregnancy with audit
against targets.
Removal of dipsticks for leucocytes and
nitrites from antenatal clinics.
Care pathway for detection and
management of asymptomatic
bacteriuria of pregnancy with audit
against targets.
Audit of antibiotics prescribed
to pregnant women against local
guidance.
Asymptomatic bacteriuria detected during
pregnancy should be treated with an
antibiotic.
3.3
C
Women with bacteriuria confirmed by a
second urine culture should be treated and
have repeat urine culture at each antenatal
visit until delivery.
3.3

Women who do not have bacteriuria in the
first trimester should not have repeat urine
cultures.
Care pathway for detection and
management of asymptomatic
bacteriuria of pregnancy with audit
against targets.
27
Management of suspected bacterial urinary tract infection in adults
7.3.3MANAGEMENT OF BACTERIAL UTI IN PATIENTS WITH CATHETERS
Recommendation
5.1
D
Clinical symptoms or signs are not
recommended for predicting the
likelihood of symptomatic UTI in
catheterised patients.
5.1

In a catheterised patient who presents
with a fever:
 look for associated localising (loin or
suprapubic tenderness) or systemic
features
 exclude other potential sources of
infection
 send off an appropriately taken urine
sample for culture to determine the
infecting organism and susceptibilities
 consider antibiotic therapy taking
into account the severity of the
presentation and any comorbid
factors.
5.1

and
5.5
5.2.1 C
5.2.2 B
5.3
A
5.4.1 
28
Urine samples from patients with catheters
or ureteric stomas should only be sent
for laboratory culture if the patient
has clinical sepsis, not because the
appearance or smell of the urine suggests
that bacteriuria is present.
Laboratory microscopy for diagnosing
UTI in catheterised patients is not
recommended.
Dipstick testing should not be used to
diagnose UTI in catheterised patients.
Antibiotic prophylaxis is not
recommended for the prevention of
symptomatic UTI in catherised patients.
Catheterised patients with symptoms or
signs of acute UUTI should be treated
with ciprofloxacin or co-amoxiclav for
seven days.
5.4.1 
Urine should be taken for culture before
treatment is started, treatment should be
changed if the organism is resistant to the
chosen antibiotic.
5.4.1 B
Patients with long term indwelling
catheters should have the catheter
changed before starting antibiotic
treatment for symptomatic UTI.
5.4.2 B
Catheterised patients with asymptomatic
bacteriuria should not receive antibiotic
treatment.
Implementation or audit
Care pathway for diagnosis of
symptomatic UTI in catheterised
patients with audit against practice.
Audit of clinical evidence of infection
in patients with long term catheters or
ureteric stomas who have been treated
with antibiotics or had urine samples
sent for culture.
Care pathway for diagnosis of
symptomatic UTI in catheterised
patients with audit against practice.
Percentage of patients with long term
catheters who receive antibiotics with
no clinical evidence of symptomatic
UTI.
Antibiotic selection for patients with
symptomatic UTI compared with local
policy recommendations.
Audit of catheter change prior to
commencing antibiotic.
Audit of clinical evidence of infection
in patients with long term catheters or
ureteric stomas who have been treated
with antibiotics or had urine samples
sent for culture.
7 RECOMMENDATIONS FOR IMPLEMENTATION, AUDIT, SURVEILLANCE AND RESEARCH
7.4recommendations for surveillance
There should be routine sampling of urine for culture from all patients presenting with acute
urinary symptoms in some selected practices to establish the true level of resistance in bacteria
causing acute UTI in general practice. Primary research may be required to provide evidence
to support details of surveillance (for example, sample sizes, frequency of surveillance studies
and geographical location of practices).
There should be surveillance of catheter associated urinary tract infection (CAUTI) using the
Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP) developed audit
tool (www.show.scot.nhs.uk/scieh/) to allow measurement of catheterisation and catheter care
practice against the best practice statement “Urinary Catheterisation and Catheter Care” 144 which
was developed and implemented by the Scottish Ministerial Healthcare Associated Infection
(HAI) Task Force.
7.4.1
Useful websites for SURVEILLANCE and infection control
NHS Scotland e-library HAI Managed Knowledge Network portal: www.elib.scot.nhs.uk
British Society for Antimicrobial Chemotherapy (BSAC): www.bsac.org.uk/
SACAR (Department of Health’s Specialist Advisory Committee on Antimicrobial Resistance):
www.advisorybodies.doh.gov.uk/sacar
National Electronic Library of Infection: www.neli.org.uk
7.5recommendations for research









What is the risk of misdiagnosis, including STDs, after patients with suspected UTI have
telephone consultation and antibiotic prescribing by nurse practitioners?
How effective are near patient tests when compared to a reliable method for diagnosing
asymptomatic bacteriuria in pregnant women?
Which antibiotics are most effective for prevention and treatment of recurrent UTI in
men?
Are cranberry products effective for prevention and treatment of recurrent UTI in men?
Is methenamine prophylaxis effective for the prevention of symptomatic UTI in elderly,
institutionalised, catheterised patients?
What are the most effective ways of questioning patients to elicit the most relevant information
to aid diagnosis and treatment?
What are the most effective methods of communication between healthcare professionals
and patients about symptoms and factors that relate to a potential infection?
What is the impact of UTI and its treatment (including side effects) on patients’ quality of
life?
What are patients’ attitudes and expectations towards treatment and what personal strategies
do they have for self care?
29
Management of suspected bacterial urinary tract infection in adults
8
Development of the guideline
8.1introduction
SIGN is a collaborative network of clinicians, other healthcare professionals and patient
organisations and is part of NHS Quality Improvement Scotland. SIGN guidelines are developed
by multidisciplinary groups using a standard methodology based on a systematic review of the
evidence. Further details about SIGN and the guideline development methodology are contained
in “SIGN 50; A Guideline Developer’s Handbook”, available at www.sign.ac.uk
8.2the guideline development group
Professor Peter Davey
(Chair)
Dr Derek Byrne
Ms Norma Craig
Dr David Evans
Professor Tom Fahey
Dr Ian Gould
Mr Robin Harbour
Ms Karen Harkness
Dr Roberta James
Ms Brin Jardine
Dr Ross Langlands
Ms Helen Macdonald
Dr Robert Masterton
Professor Dilip Nathwani
Dr Erica Peters
Ms Valerie Sillito
Ms Doreen Simpson
Professor of Pharmoeconomics, Medicines Monitoring Unit, Ninewells Hospital and Medical School, Dundee
Consultant Surgeon and Urologist,
Ninewells Hospital and Medical School, Dundee
Lead Nurse - Continence, Whitehills Health and
Community Care Centre, Forfar
Consultant Obstetrician, Dr Gray’s Hospital, Elgin
Professor of General Practice, University of Dundee
Consultant in Clinical Microbiology,
Aberdeen Royal Infirmary
Quality and Information Director, SIGN
Principal Pharmacist, Ninewells Hospital and
Medical School, Dundee
Programme Manager, SIGN
Lay representative, Edinburgh
General Practitioner, Newton Port Surgery, East Lothian
Health Protection Nurse Specialist,
Highland NHS Board, Inverness
Medical Director, Crosshouse Hospital, Kilmarnock
Consultant Physician, Infection Unit,
Ninewells Hospital and Medical School, Dundee
Special Registrar in Infectious Diseases,
Brownlea Centre, Gartnavel Hospital, Glasgow
Community Pharmacist, Woodend Hospital, Aberdeen
Community Staff Nurse, Green Street Surgery, Forfar
The membership of the guideline development group was confirmed following consultation
with the member organisations of SIGN. All members of the guideline development group
made declarations of interest and further details of these are available on request from the SIGN
Executive. Guideline development and literature review expertise, support and facilitation were
provided by the SIGN Executive.
8.3
acknowledgements
SIGN is grateful to the following former members of the guideline development group and
others who have contributed to the development of this guideline.
Ms Fiona Brandt
Dr Ali El-Ghorr
Dr Michael Power
Dr Kate Woodman
30
Practice Nurse, Aberlour
Programme Manager, SIGN
Clinical Knowledge Author, Guideline Developer
and Informatician, Prodigy Knowledge, Newcastle
Lay representative, Edinburgh
8 DEVELOPMENT OF THE GUIDELINE
8.4systematic literature review
The evidence base for this guideline was synthesised in accordance with SIGN methodology.
A systematic review of the literature was carried out using an explicit search strategy devised
by the SIGN Information Officer in collaboration with members of the guideline development
group.
Literature searches were initially conducted in Medline, Embase, Cinahl, and the Cochrane
Library using the year range 1994-2002. The literature search was extended from 1966-2003
for RCTs and diagnostic studies. The National Economic Evaluation Database (NEED) was
searched for economic studies to cover the period up to January 2004. Key websites on the
Internet were also searched. These searches were supplemented by the reference lists of relevant
papers and group members’ own files. The Medline version of the main search strategies can
be found on the SIGN website.
8.5consultation and peer review
8.5.1national open meeting
A national open meeting is the main consultative phase of SIGN guideline development, at
which the guideline development group presents its draft recommendations for the first time.
The national open meeting for this guideline was held on 30 April 2004 and was attended by
representatives of all the key specialties relevant to the guideline. The draft guideline was also
available on the SIGN website for a limited period at this stage to allow those unable to attend
the meeting to contribute to the development of the guideline.
8.5.2specialist review
This guideline was also reviewed in draft form by the following independent expert referees,
who were asked to comment primarily on the comprehensiveness and accuracy of interpretation
of the evidence base supporting the recommendations in the guideline. SIGN is very grateful
to all of these experts for their contribution to the guideline.
Dr James Beattie
Mr Graeme Conn
Mrs Beatrice Grant
Dr Mary Hanson
Dr Diana Holton
Ms Cathy McKerrell
Dr Allan Merry
Dr Dorothy Moir
Professor Sigvard Molstad
Dr Lindsay Nicolle
Dr Ewan Olson
Professor Raul Raz
Dr Maureen Simpson
Professor Francisco Soriano
Dr Charles Swainson
Dr Alex Watson
Dr Craig Williams
Director of Guidelines Development, Royal College of General Practitioners/General Practitioner, Aberdeenshire
Consultant Urological Surgeon,
Southern General Hospital, Glasgow
Lay Reviewer, Larbert
Consultant Microbiologist,
Western General Hospital, Edinburgh
Hospital Practitioner, Roodlands Hospital, East Lothian
Project Manager (Scotland), Incontact, Lanarkshire
General Practitioner, South Beach Surgery, Ardrossan
Director of Public Health, NHS Lanarkshire
Professor of General Practice,
Primärvardens FoU-enhet, Sweden
Professor of Internal Medicine and Medical Microbiology,
University of Manitoba, Canada
Consultant Microbiologist, Royal Infirmary of Edinburgh
Director, Infectious Diseases Unit,
Haemek Medical Centre, Israel
General Practitioner, Townhead Practice, Montrose
Professor of Microbiology, Fundacion Jimenez Diaz, Madrid
Medical Director, Lothian NHS Board, Edinburgh
General Practitioner, West Gate Health Centre, Dundee
Consultant Medical Microbiologist,
Yorkhill NHS Trust, Glasgow
31
Management of suspected bacterial urinary tract infection in adults
8.5.3sign editorial group
As a final quality control check, the guideline is reviewed by an editorial group comprising
the relevant specialty representatives on SIGN Council to ensure that the specialist reviewers’
comments have been addressed adequately and that any risk of bias in the guideline
development process as a whole has been minimised. The editorial group for this guideline
was as follows:
Professor Gordon Lowe
Dr David Alexander
Dr Bill Reith
Dr Safia Qureshi
Dr Sara Twaddle
32
Chair of SIGN; Co-Editor
General Practitioner, Nethertown Surgery, Dunfermline
Royal College of General Practitioners,
General Practitioner, Aberdeen
SIGN Programme Director; Co-Editor
Director of SIGN; Co-Editor
ABBREVIATIONS
Abbreviations
BNF
British National Formulary
BSAC
British Society for Antimicrobial Chemotherapy
CAUTI
catheter associated urinary tract infection
CBA
controlled before and after study
cfu
colony forming units
CI
confidence interval
CSM
Committee on Safety of Medicines
CSU
catheter specimen of urine
GP
general practitioner
HAI
healthcare associated infection
HPA
Health Protection Agency
IDSA
Infectious Diseases Society of America
INR
International Normalized Ratio
KUB
kidneys, ureters and bladder
LE
leucocyte esterase
LUTI
lower urinary tract infection
MIC
minimum inhibitory concentration
MSU
midstream specimen of urine
NeLI
National electronic Library of Infection
NNT
number needed to treat
NNTB
number needed to benefit
NNTH
number needed to harm
PPROM
pre-labour, premature rupture of membranes
PPV
positive predictive value
QALY
quality adjusted life year
RCT
randomised controlled trial
SACAR
Department of Health’s Specialist Advisory Committee on Antimicrobial Resistance
SIGN
Scottish Intercollegiate Guidelines Network
SPA
suprapubic aspirate
SSHAIP
Scottish Surveillance of Healthcare Associated Infection Programme
STD
sexually transmitted disease
UTI
urinary tract infection
UUTI
upper urinary tract infection
WBC
white blood cells
33
Management of suspected bacterial urinary tract infection in adults
Annex 1
MANAGEMENT OF SUSPECTED LUTI IN WOMEN (not pregnant)
NO
Vaginal itch
or discharge?
Symptoms and signs of UTI?
 dysuria
 urgency
 frequency
 polyuria
 suprapubic tenderness
 fever
 flank or back pain
Limited (no more than
two) symptoms
c In women with symptoms of vaginal
itch or discharge, explore alternative
diagnoses and consider pelvic
examination.
c Dipstick tests should only be used to
diagnose bacteriuria in women with
limited symptoms and signs.
Dipstick
positive
Multiple
symptoms
Fever &
back pain?
YES
b  Non-pregnant NO, LUTI probable
YES
 Consider the possibility of UUTI.
women of any age with
symptoms or signs of acute LUTI should be treated with trimethoprim or nitrofurantoin for three days.
Dipstick negative
or equivocal
b  Offer empirical Patients who do not respond to trimethoprim or nitrofurantoin should have urine taken for culture to guide change of antibiotic.
antibiotic treatment.

The risks and benefits of empirical treatment should be discussed with the patient and managed accordingly.

If a woman remains symptomatic after a single course of treatment, investigate other potential causes.
 Quinolones should not be used for empirical
treatment of LUTI.
 Women with renal impairment should not be
treated with nitrofurantoin.
d Women prescribed nitrofurantoin should not
take alkanalising agents (potassium citrate).
34
ANNEXES
Annex 2
MANAGEMENT OF SUSPECTED UUTI IN WOMEN (not pregnant)
Signs and symptoms of UUTI:
 loin pain
 flank tenderness
 fever
 rigors
 other manifestations of systemic inflammatory response
UUTI can be accompanied by bacteraemia,
making it a life-threatening condition
NO
YES
Systemic symptoms?
A Non-pregnant women with symptoms or signs of
acute UUTI should be treated with ciprofloxacin for
seven days.
D Urine should be taken for culture before immediate
empirical treatment is started and treatment changed if
there is an inadequate response to the antibiotic.
If no response to
treatment in 24 hours
 Admit to hospital
35
Management of suspected bacterial urinary tract infection in adults
Annex 3
MANAGEMENT OF SUSPECTED LUTI IN PREGNANT WOMEN
Symptomatic bacteriuria
(occurs in 17-20% of pregnancies)
B
Treat with an antibiotic.
Screening for
asymptomatic bacteriuria
A
Standard quantitative urine culture
should be performed routinely at
first antenatal visit.
A
Dipstick testing should not be used
to screen for bacterial UTI.
  a single urine sample 


should be taken for culture before empiric antibiotic treatment is started
refer to local guidance for the safest, cheapest, effective antibiotic
refer to the British National Formulary (BNF) for contraindications in pregnancy
a urine culture should be performed seven days after completion of antibiotic treatment as a test of cure.
 Women who do not
Culture positive?
NO
YES
A The presence of bacteriuria in urine
should be confirmed with a second
urine culture.
A
Treat with an antibiotic.
 Refer to local guidance for the safest,
cheapest, effective antibiotic.
A
36
Repeat urine culture at each antenatal
visit until delivery.
have bacteriuria in
the first trimester
should not have
repeat urine
cultures.
ANNEXES
Annex 4
MANAGEMENT OF SUSPECTED UTI IN ADULT MEN
Symptoms and signs of UTI?
 dysuria
 urgency
 frequency
 polyuria
 suprapubic tenderness
 fever
 flank or back pain
Differential diagnosis should include
prostatitis, chlaymidial infection, epididymitis
 In all men with symptoms of UTI
History of fever or back pain
a urine sample should be taken for
culture.
 Consider the possibility of UUTI
c
Treat empirically with a two week course
of quinolone.
 Urine culture should guide the choice of antibiotic.
If no response
to antibiotic
Recurrent UTI?
YES
 Investigate for
prostatitis.
d
Refer for urological
investigation
NO
B
Treat empirically with a two week course
of quinolone.
A
Elderly men with asymptomatic
bacteriuria should not receive antibiotic
treatment.
37
Management of suspected bacterial urinary tract infection in adults
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NO
Symptoms and signs of UTI?
 dysuria
 urgency
 frequency
 polyuria
 suprapubic tenderness
 fever
 flank or back pain
Multiple
symptoms
Fever &
back pain?
YES
YES
c
c
Non-pregnant women of any age with symptoms or signs of acute LUTI should be treated with trimethoprim or nitrofurantoin for three days.


If a woman remains symptomatic after a single course of treatment, investigate other potential causes.
The risks and benefits of empirical treatment should be discussed with the patient and managed accordingly.
b  Offer empirical antibiotic treatment.
Dipstick negative
or equivocal
Dipstick tests should only be used to
diagnose bacteriuria in women with
limited symptoms and signs.
b 
Patients who do not respond to trimethoprim or nitrofurantoin should have urine taken for culture to guide change of antibiotic.
Dipstick
positive

treatment of LUTI.
 Quinolones should not be used for empirical
treated with nitrofurantoin.
 Women with renal impairment should not be
take alkanalising agents (potassium citrate).
d Women prescribed nitrofurantoin should not
Signs and symptoms of UUTI:
 loin pain
 flank tenderness
 fever
 rigors
 other manifestations of systemic
inflammatory response
UUTI can be accompanied by bacteraemia,
making it a life-threatening condition
YES
A
Non-pregnant women with symptoms or signs of
acute UUTI should be treated with ciprofloxacin for
seven days.
Systemic symptoms?
D
If no response to
treatment in 24 hours
 Admit to hospital
Urine should be taken for culture before immediate
empirical treatment is started and treatment changed if
there is an inadequate response to the antibiotic.
NO
MANAGEMENT OF SUSPECTED UUTI IN WOMEN (not pregnant)
Management of suspected bacterial urinary tract infection in adults
Vaginal itch
or discharge?
Limited (no more than
two) symptoms
NO, LUTI probable
 Consider the possibility of UUTI.
In women with symptoms of vaginal
itch or discharge, explore alternative
diagnoses and consider pelvic
examination.
MANAGEMENT OF SUSPECTED
LUTI IN WOMEN (not pregnant)
MANAGEMENT OF SUSPECTED LUTI IN WOMEN (not pregnant)
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